Provider Demographics
NPI:1497141311
Name:PELICAN STATE FOOT & ANKLE CARE LLC
Entity Type:Organization
Organization Name:PELICAN STATE FOOT & ANKLE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:985-867-0301
Mailing Address - Street 1:PO BOX 1228
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71309-1228
Mailing Address - Country:US
Mailing Address - Phone:985-867-0301
Mailing Address - Fax:
Practice Address - Street 1:1938 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-6437
Practice Address - Country:US
Practice Address - Phone:985-867-0301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPM.200036213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty